ARE CORRECT AGRADE
a nurse is completing a nutritional assessment on a client and measures BMI, which of the
following readings correlates with a BMI of an overweight client? - ANSWER-25
(25-29.9)
a nurse is verifying ng tube placement by the pH of aspirated gastric fluid. which of the
following pH values provides a good indication of correct tube placement? - ANSWER-2
(pH between 0-4)
a nurse is caring for a client with a closed head injury. when pressure is applied to the client's
nail beds, the clients eyes open and adduction of the arms with flexion of the elbows and wrists
is noted. the client also moans with stimulation, what is the GCS? - ANSWER-7
eye opening 1-4
verbal 1-5
motor 1-6
a nurse should teach which of the following clients requiring crutches about how to use a three
point gait? - ANSWER-a client who has a R femur fracture with no weight bearing on the
affected leg
(bears all weight on one foot, then both shoulders on crutches, and uninvolved leg, the affected
leg does not touch the ground)
a nurse is providing teaching about the Mediterranean diet to a client newly who has a new
diagnosis of hypertension. what statement indicates need for further teaching? - ANSWER-i will
limit my intake of red meat to 2x weekly
(should be limited to 2x monthly)
a nurse is providing dietary education to a client with cholecystitis who has been prescribed a
low-fat diet. which of the following meal selections by the client indicates understanding of
education? - ANSWER-roast turkey, rice pilaf, green beans
, a client with cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent
pelvic organ prolapse. What exercise will the client need to perform - ANSWER-Kegals
(reduce pelvic prolapse and stress urinary incontinence)
a nurse is caring for an older adult client with delirium. which intervention will most likely
reduce the client's risk for falls? - ANSWER-hourly rounding by the nurse
a nurse is caring for a client who has been prescribed furosemide. which of the following foods
should the nurse encourage this to include in his diet? - ANSWER-oranges
(along with dried fruits, tomatoes, avocados, dried peas, meats, broccoli, bananas are good for
a potassium wasting diuretic)
a menopausal client is having difficulty getting to sleep and asks what actions she should
incorporate in her daily routine to promote sleep. the nurse would encourage, which of the
below measures to promote sleep? - ANSWER-limit alcohol and nicotine prior to bedtime
(at least 4 hours)
a nurse is caring for several clients prescribed heat/cold therapies. which of the following clients
are at risk of injury from these therapies? SATA - ANSWER-use caution with clients who are very
young, older adult, fair skinned, impaired cognition, and comorbidities --> higher risk for fragile
skin
a nurse is caring for a client with HF who has evidence of dyspnea, bibasalar crackles and frothy
sputum. what dietary recommendations should be provided to this client in management of
their HF? - ANSWER-reduce sodium intake
(stop smoking, monitor fluid intake to 2L/d, increase protein, consume small frequent meals
that are soft and easy to chew)
a nurse is caring for a client receiving opiates for PM, initially after PM plan was started the
client was sedated and sleeping most of the time. after three days the client is no longer
sedated and sleeping regularly. what action should the nurse take? - ANSWER-no action is
needed at this time